S. 3389 — Lowering Health Care Costs for Americans Act

This section establishes minimum monthly premium payments that premium tax credit recipients under the Affordable Care Act must pay out-of-pocket—$10 if household income is under 200% of the federal poverty line, $20 if 200%-under 300%, $30 if 300%-under 400%, and $40 if 400% or more—by limiting the maximum premium assistance amount accordingly, for taxable years beginning after December 31, 2025. (Thus, the credit covers the benchmark plan premium minus these minimum amounts, even if the benchmark premium is lower.)

This section requires applicants for enrollment in a qualified health plan offered through an Exchange in the individual market to provide government-issued photo identification for each enrollee over the age of 18, and any other documentation as required by the Administrator of the Centers for Medicare & Medicaid Services (CMS) for enrollment verification. (As background, this modifies the ACA program that verifies eligibility for Exchange coverage, premium tax credits, reduced cost-sharing, unaffordable employer coverage, and individual mandate exemptions. Thus, it adds documentation requirements to the existing mandates for name, address, date of birth, Social Security number, and immigration information.)

This section requires American Health Benefit Exchanges, for plan years beginning after December 31, 2026, and before January 1, 2032, to facilitate enrollment in Healthcare Affordability Accounts (HAAs under IRC §223(i)) for qualified individuals purchasing qualified health plans (QHPs) who are eligible for premium tax credits (PTCs under IRC §36B); directs the Secretary to establish a notification procedure for such individuals regarding the need to enroll in an HAA to receive the PTC; and requires Exchanges to provide a link to the Department of the Treasury's HAA application website on their webpages. (As background, Exchanges are ACA-established marketplaces that facilitate QHP purchases by individuals and small businesses, with PTCs subsidizing premiums for eligible lower-income enrollees.) It further revises advance PTC payments under ACA §1412 to, for plan years beginning after December 31, 2026, and before January 1, 2032, deposit them into HAAs (with cost-sharing reductions paid directly to QHP issuers) and, before January 1, 2031, make such deposits monthly or on another periodic basis as specified by the Secretary of the Treasury. (Thus, eligible individuals must enroll in HAAs during this period to access PTC subsidies.)

This section establishes Healthcare Affordability Accounts as a type of health savings account (HSA) under IRC §223(i). (Health savings accounts are tax-advantaged vehicles available to individuals with high-deductible health plans to pay for qualified medical expenses.) For such accounts, the section (1) excludes amounts transferred under ACA §1412 from the contribution deduction; (2) treats the account as an individual's sole HSA, with rollover permitted from any prior HSA but prohibiting contributions or rollovers to other HSAs; and (3) bars use of account funds for gender transition procedures or abortion. Gender transition procedures are defined to include an enumerated list of 33 hormonal or surgical interventions (e.g., puberty blockers, castration, vaginoplasty, mastectomy) intended to change an individual's biological sex, with exclusions for certain disorders of sex development, infections or injuries from prior procedures, imminent physical dangers, precocious puberty treatment, and male circumcision.

This section extends the temporary enhanced premium tax credits under the premium tax credit (PTC) program—which subsidizes Affordable Care Act (ACA) marketplace health insurance premiums by capping enrollee contributions at 8.5% of income and waiving the 400% federal poverty level (FPL) eligibility limit—through taxable year 2031 (from 2025), with modifications. Specifically, it (1) extends the disregard of the 400% FPL limit through 2031 (from 2025); (2) extends and revises the household income limitation rule to apply through 2031 (from 2025), substituting 700% FPL for 400% FPL during 2027-2031; and (3) phases down the enhanced credit amount—which is the excess subsidy due to the temporary waiver—by 20% for 2028, 40% for 2029, 60% for 2030, and 80% for 2031. (Thus, the full enhancements apply through 2027, after which they gradually revert toward pre-2021 levels.) The changes apply to taxable years beginning after December 31, 2025.

This section revises rules under ACA Section 1303(b) prohibiting the use of federal funds for non-Hyde Amendment abortion coverage (i.e., abortions ineligible for federal funding) in qualified health plans (QHPs) offered through an Exchange, expands related enrollee payment requirements, and establishes notice rules, effective for plan years beginning after December 31, 2026. Specifically, it (1) limits the prohibition to cost-sharing reductions under ACA Section 1402 and their advance payments under Section 1412 (previously also including premium tax credits under IRC Section 36B and their advance payments under ACA Section 1412); (2) requires QHP issuers to collect separate enrollee payments into allocation accounts for both those cost-sharing reductions and premium tax credits under IRC Section 36B (and their advance payments under ACA Section 1412); and (3) requires QHPs offering such coverage to provide enrollees with notice of the coverage, the separate premium charged for it (ineligible for premium tax credits), and related disclosures in summary of benefits and Exchange comparative information. (Thus, premium tax credits may subsidize QHP premiums that include non-Hyde abortion coverage, subject to fund segregation via separate payments.)

This section excludes from the premium tax credit calculation the portion of a qualified health plan's premium properly allocable to coverage of abortion (as defined in IRC §223(i)(7)(F)), as determined under rules prescribed by the Secretary of Health and Human Services. (Thus, premium tax credit recipients enrolled in such a plan must pay the full unsubsidized cost of any abortion coverage.) The provision applies to taxable years beginning after December 31, 2026.

This section expands health insurance coverage reporting requirements under IRC §6055 for qualified health plans (QHPs) offered through ACA Exchanges to include (aa) total monthly enrollment premiums, (bb) monthly enrollment premiums attributable to coverage of abortion services (per ACA §1303(b)), and (cc) advance payments of premium tax credits (PTCs) under ACA §1412 with respect to such coverage—for taxable years beginning after December 31, 2026. (Previously, QHP reporting included only advance PTC payments.) (Thus, enables IRS verification that PTCs do not subsidize abortion coverage, consistent with ACA §1303 prohibitions on federal funding thereof.)

This section modifies the definition of qualified health plan (QHP) under the Patient Protection and Affordable Care Act (ACA) to require that such plans—certified for sale on ACA Exchanges (i.e., Health Insurance Marketplaces) and eligible for premium tax credits—do not provide coverage for gender transition procedures. It defines gender transition procedure to include hormonal interventions (e.g., puberty blockers, supraphysiologic sex hormones) and surgical procedures (e.g., castration, hysterectomy, vaginoplasty, mastectomy) intended to alter an individual's sex characteristics, with exclusions for services addressing disorders of sex development, infections or injuries from prior procedures, imminent physical dangers, precocious puberty, and male circumcision; it also defines related terms including sex, male, female, and gender transition. The amendments apply to plan years beginning on or after January 1, 2026. (Thus, QHPs may not cover gender transition procedures for enrollees, including transgender individuals, starting in 2026.)

This section establishes mandatory funding for cost-sharing reduction (CSR) payments under the ACA by appropriating such sums as necessary from any funds in the Treasury not otherwise appropriated for qualified health plans (QHPs) enrolled by eligible individuals (i.e., those with household incomes of 100-400% of the federal poverty level) for plan years beginning on or after January 1, 2026. It prohibits use of these funds for CSR payments to QHPs providing abortion coverage, except when necessary to save the mother's life or resulting from rape or incest. (As background, CSRs require issuers to reduce enrollees' out-of-pocket limits, deductibles, and copayments in silver-level QHPs offered through ACA Exchanges, with reductions of two-thirds for 100-200% FPL, one-half for 200-300% FPL, and one-third for 300-400% FPL.)

This section revises the state innovation waiver program under Section 1332 of the Patient Protection and Affordable Care Act (i.e., allowing states to waive certain ACA requirements—including health insurance exchanges under ACA Part A, consumer protections under Part B, risk adjustment payments under Section 1331, premium tax credits and individual mandate under IRC Section 36B and 5000A, and employer mandate under IRC Section 4980H—for plan years beginning on or after January 1, 2017, if the state has a budget-neutral alternative plan). Specifically, it (1) streamlines the application process by permitting a governor's certification of authority (in lieu of state legislation under prior law) and allowing waiver termination via certification revocation; (2) expands pass-through funding under subsection (a)(3) to include reduced amounts of premium tax credits, cost-sharing reductions, small business credits, and basic health program funds under ACA Section 1331, with states able to request all or a portion of such aggregate funds (previously, only full amounts otherwise unavailable due to waiver structure); and (3) establishes new subsection (a)(4) requiring the Secretary of HHS, within 45 days of enactment and in consultation with the National Association of Insurance Commissioners, to specify an allocation methodology for grants to states from newly appropriated funds—$500 million for FY2027 and $5 billion annually for FY2028 through FY2030 (available until expended)—to support invisible high-risk pools or reinsurance programs meeting new requirements under subsection (g)(2), with FY2027 grants for administrative costs and preparation and FY2028-FY2030 grants for establishment or maintenance (such funds excluded from budget neutrality calculations). (Thus, for plan year 2026, if a state lacks an approved waiver with a qualifying high-risk pool or reinsurance program by a Secretary-specified date, allocated funds default to federal market stabilization payments to issuers.)

This section revises hospital price transparency requirements under section 2718(e) of the Public Health Service Act (42 U.S.C. 300gg-18(e)) to require each hospital to compile and make public monthly, without subscription and free of charge, in formats specified by the Secretary of Health and Human Services: (1) all standard charges for each item and service provided by the hospital; and (2) consumer-friendly hospital standard charge information covering at least 300 shoppable services through December 31, 2026 (after which all shoppable services must be included), including indicators for any Centers for Medicare & Medicaid Services-specified shoppable services not provided. Standard charges must include (i) plain-language descriptions with applicable billing codes (e.g., CPT, HCPCS); (ii) gross charges for inpatient and outpatient settings; (iii) discounted cash prices (or minimum cash prices accepted from self-pay individuals if unavailable), which the hospital must accept as payment in full, plus for consumer-friendly disclosures a link explaining the charity care policy; (iv) payer-specific negotiated charges (expressed as dollar amounts and associated with payer/plan names), including any algorithms, formulas, or contract terms used to derive them; (v) de-identified maximum and minimum negotiated charges; and (vi) additional information required by the Secretary to improve accuracy and comparability. Not later than January 1, 2026, the Secretary must establish uniform methods and formats for these disclosures, including machine-readable spreadsheets for standard charges, with updates as needed in consultation with stakeholders. Price estimator tools do not satisfy these requirements. The Secretary must monitor compliance annually in consultation with the HHS Inspector General, and a senior hospital official (e.g., CEO or CFO) must attest to the accuracy and completeness of disclosures.

This section establishes clinical diagnostic laboratory price transparency requirements under Section 2718 of the Public Health Service Act, applicable beginning July 1, 2027. Applicable laboratories must publicly post on their websites, and update monthly if changed, the following for each specified clinical diagnostic laboratory test: (1) plain-language description with applicable billing codes (e.g., CPT, HCPCS); (2) gross charge; (3) discounted cash price (or minimum cash price accepted from self-pay patients over prior three years, with charity care policy link), which the lab must accept as payment in full from cash-paying patients; (4) payer-specific negotiated charges by third-party payer and plan name for inpatient and outpatient settings (including any formulas, algorithms, or contract terms used); (5) de-identified maximum and minimum negotiated charges; and (6) additional Secretary-required information to aid consumer understanding and comparison (except duplicative data). Prices must include ancillary services (e.g., specimen collection, transport); the Secretary must specify a uniform machine-readable format (e.g., spreadsheet) by January 1, 2027; and the Secretary must provide technical assistance for compliance. For noncompliance, the Secretary must notify the lab and may impose civil monetary penalties of up to $300 per day starting 90 days after notification (increasable after 2027), with certain Social Security Act enforcement provisions applying.

This section establishes price transparency requirements for specified imaging services furnished by providers of services and suppliers (other than those for which standard charges are disclosed by a hospital under subsection (e)), effective July 1, 2027. Such providers and suppliers must annually publish on an internet website, in a uniform machine-readable format specified by the Secretary by January 1, 2027, the following information for each service: (1) plain language descriptions with applicable billing codes (e.g., CPT, HCPCS); (2) gross charge; (3) discounted cash price (or minimum cash price accepted from self-pay patients over prior three years, with charity care policy link); (4) payer-specific negotiated charges (including algorithms, formulas, and contract terms); (5) de-identified maximum and minimum negotiated charges; and (6) additional information required by the Secretary. The Secretary must monitor compliance through notice-and-comment rulemaking and may impose civil monetary penalties of up to $300 per day for ongoing violations following notice and a 90-day opportunity for corrective action.

This section requires specified ambulatory surgical centers to publicly disclose, without subscription and free of charge beginning July 1, 2027, standard charges in machine-readable format for each item and service and prices in consumer-friendly format for at least 300 shoppable services (including all Centers for Medicare & Medicaid Services-specified shoppable services furnished by the center plus additional center-selected services, or an indication if a specified service is not furnished). Disclosures must include (1) a description with applicable coding (e.g., Healthcare Common Procedure Coding System code); (2) gross charge; (3) discounted cash price (or minimum cash price accepted from self-pay individuals over prior three years if unavailable, with a charity care policy link for shoppable services), which the center must accept as payment in full from cash-paying patients regardless of coverage; (4) payer-specific negotiated charges clearly associated with each third-party payer and plan (including any algorithms, formulas, or contract terms used to calculate them); and (5) de-identified maximum and minimum negotiated charges. The Secretary of Health and Human Services must establish uniform methods and formats by January 1, 2027 (updatable as needed); price estimator tools do not satisfy these requirements; the Secretary must monitor compliance annually in consultation with the HHS Inspector General; and the Secretary must notify noncompliant centers within 30 days of determining a violation. (As background, these requirements mirror and expand hospital price transparency rules under existing subsection (e.g., of Section 2718), enabling consumers to compare ASC charges including negotiated insurer rates.)

This section revises transparency requirements for Affordable Care Act Exchanges by expanding the self-service tool for individuals to obtain, for any provider and item or service, (1) in-network rates or out-of-network maximum allowed amounts; (2) applicable cost-sharing amounts (calculated using out-of-network maximums where relevant); (3) accumulated deductibles or out-of-pocket maximums; (4) accrued amounts toward frequency or volume limits; and (5) prior authorization or similar requirements. It further requires the tool to be internet-based with real-time responses using billing codes or descriptive terms, hold enrollees harmless for discrepancies between tool estimates and actual bills, and offer paper or phone disclosures at no cost. This section also requires each health plan, beginning January 1, 2027 and monthly thereafter, to publicly disclose and submit to Exchanges, the Secretary, and state insurance commissioners detailed in-network rates (by provider NPI and codes such as CPT, HCPCS, DRG, or NDC) for all covered items and services (excluding low/no-claim providers) and, for drugs, both current in-network rates and historical net prices (net of rebates) from the prior 90-day period ending 180 days earlier.

This section amends the ERISA statutory exemption for reasonable service contracts with parties in interest (29 U.S.C. 1108(b)(2)) to provide that, for group health plans, no contract or arrangement—including extensions or renewals—with covered service providers (i.e., health care providers or facilities, provider networks, third-party administrators, or pharmacy benefit managers) is reasonable unless it (1) allows responsible plan fiduciaries access to all claims and encounter information, supporting documentation (e.g., medical records), and related data to ensure plan compliance and payment accuracy; and (2) prohibits unreasonable limits or delays on such access (e.g., not longer than 15 days), limits on data volume or audit rights, nondisclosure of pricing terms (including for value-based or capitated arrangements), overpayment recovery terms, administrative fees, or suspect claim actions, or restrictions on daily batch access or de-identified data disclosure. (As background, the section 408(b)(2) exemption permits ERISA plans to contract for necessary services without violating prohibited transaction rules, protecting plans and participants from self-dealing.) It further requires such data to be provided in HIPAA-compliant formats and specific electronic standards (e.g., ASC X12N 837 for claims, ASC X12N 835 for remittances) at no cost to the plan, with group health plans limited to HIPAA-compliant disclosures of received data.

This section adds a new section 726 to ERISA (29 U.S.C. 1021 et seq.) prohibiting agreements between group health plans (or their sponsors, administrators, business associates, or health insurance issuers) and health plan service providers (e.g., health care providers, third-party administrators, pharmacy benefit managers) from limiting or delaying disclosure of specified information to such plans or issuers. For plan years beginning two years after enactment, health plan service providers must disclose the following information quarterly at no cost: (1) information described in ERISA section 724(a)(1)(B); (2) contractual and subcontractual calculation methodologies, pricing or fee schedules, and related formulae used to determine provider reimbursements; (3) total amounts received or expected from rebates, fees, discounts, and other remuneration; (4) total amounts paid or expected to subcontractors for such items; and (5) payment and reconciliation data for alternative compensation arrangements (e.g., accountable care organizations, bundled payments). Disclosures must comply with HIPAA privacy, security, and breach notification rules (45 C.F.R. parts 160 and 164), with redisclosure limited to specified parties; failure to disclose constitutes an ERISA violation subject to Secretary enforcement. This section also amends ERISA section 502(a)(6) (29 U.S.C. 1132(a)(6)) to authorize the Secretary to collect civil penalties under new paragraphs (13) and (14) of section 502(c) (from paragraphs (2), (4), (5), (6), (7), (8), and (9)).

This section limits the preemption under sections 201 through 204 of state laws establishing, implementing, or continuing requirements or prohibitions related to health care price transparency (e.g., for hospitals, clinical diagnostic laboratory tests, imaging services, and ambulatory surgical centers), except to the extent such state laws prevent application of the federal requirements. This section does not affect group health plans established under the Employee Retirement Income Security Act of 1974 (ERISA) or alter ERISA's preemption provision (29 U.S.C. 1144).

This section revises advanced explanation of benefits (AEOB) requirements for emergency services under the No Surprises Act—applicable to group health plans and health insurance issuers offering group or individual coverage—by requiring the good faith estimate of the plan's payment responsibility to include plain language descriptions of each item or service and all applicable billing codes (including modifiers) using standard, commonly recognized code sets that are clearly identified. It further requires such plans and issuers, for plan years beginning on or after January 1, 2026, to provide participants, beneficiaries, or enrollees (via mail or electronic means as requested) an itemized explanation of benefits within 45 days of receiving any payment request for an item or service, in clear language and substantially the same format as the AEOB to enable comparison, disclosing (1) whether the provider or facility is participating with respect to such item or service; and (2) for each item or service, a plain language description, all applicable billing codes (including modifiers) using standard, commonly recognized code sets that are clearly identified, the plan's payment amount, the individual's cost-sharing amount (as of the notification date), progress toward financial responsibility limits (including deductibles and out-of-pocket maximums, as of the notification date), and the service site. Such explanations may accompany claim determination notices, and the Secretary must implement these requirements through notice-and-comment rulemaking.

This section establishes requirements under Part E of title XXVII of the Public Health Service Act for health care providers and facilities to furnish a written itemized bill to an individual when requesting payment for health care items or services provided (including telehealth), no later than 30 days after receiving final payment from a third party. The itemized bill must include for each item or service: (1) a plain language description; (2) applicable billing codes (including modifiers) from standard sets; (3) price and billed amount (or binding bundled price); (4) payments made by or on behalf of the individual; (5) information on language-assistance services for limited English proficiency individuals; (6) contact information for discussing and correcting the bill; and (7) details on charity care policies and application instructions. This section prohibits providers or facilities from initiating collection actions against an individual for any item or service without first providing the itemized bill or if the billed amount exceeds amounts disclosed under federal price transparency regulations or a good faith estimate (unless documented as medically necessary due to unforeseen complications or patient-initiated changes, with burden of proof on the provider). Noncompliance triggers civil penalties of up to $10,000 per instance, a presumption that charges substantially exceeded the good faith estimate in patient-provider disputes, and implementation by the Secretary of Health and Human Services through notice-and-comment rulemaking.